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Difficulty: MediumBasic Care and Comfort

A nurse is developing a care plan for a client who is 48 hours postoperative following a right above-the-knee amputation. Which interventions should the nurse include to promote comfort, mobility, and proper positioning? Select all that apply.

  1. Position the client prone for 20 to 30 minutes every 3 to 4 hours.Answer
  2. B
    Elevate the right residual limb continuously on a pillow.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to evaluate the skin on the residual limb during a bed bath.
  4. Ensure an overhead trapeze bar is securely attached to the client's bed.Answer
  5. E
    Encourage the client to sit in a bedside chair for 4 consecutive hours to build endurance.
  6. Wash the residual limb gently with mild soap and water, then pat it completely dry.Answer

Answer

The correct interventions are positioning the client prone periodically, utilizing an overhead trapeze bar, and washing and drying the residual limb thoroughly.
Appropriate basic care for a client with a recent above-the-knee amputation focuses on preventing hip flexion contractures, maintaining skin integrity, and promoting independent mobility. Periodic prone positioning counteracts flexion, a trapeze bar encourages independent movement, and gentle washing with complete drying protects the vulnerable skin from breakdown.

Step-by-Step Solution

1
Analyze the client's postoperative timeframe and surgical procedure.
The client is 48 hours post-op from an above-the-knee amputation, putting them at high risk for hip flexion contractures and requiring focused skin and mobility care.
Understanding the timeline and procedure identifies contracture prevention as a primary goal.
2
Evaluate the positioning options for contracture risk.
Prone positioning stretches the hip flexors, while continuous pillow elevation and prolonged sitting promote excessive hip flexion.
Correct positioning is fundamental to basic care and maintaining future prosthesis viability.
3
Assess the delegation and hygiene interventions.
An RN must perform skin evaluations, not a UAP. A trapeze aids mobility, and proper washing prevents maceration.
Safe basic care requires appropriate task delegation and promoting optimal skin integrity.

Key Concept

Prevention of flexion contractures and promotion of safe basic care following lower extremity amputation.
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Topics

Basic Care and Comfort

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